Provider Demographics
NPI:1679657845
Name:LALLY, MICHELLE ALICIA (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:ALICIA
Last Name:LALLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:A
Other - Last Name:HEFFNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:265 W INA RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-6204
Mailing Address - Country:US
Mailing Address - Phone:520-694-8100
Mailing Address - Fax:520-694-8191
Practice Address - Street 1:265 W INA RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-6204
Practice Address - Country:US
Practice Address - Phone:520-694-8100
Practice Address - Fax:520-694-8191
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ35942207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine